Anti-vascular endothelial growth factors in combination with vitrectomy for complications of proliferative diabetic retinopathy.

BACKGROUND: Vitrectomy is an established treatment for the complications of proliferative diabetic retinopathy (PDR). However, a number of complications can occur during and after vitrectomy for PDR. These include bleeding and the creation of retinal holes during surgery, and bleeding, retinal detachment and scar tissue on the retina after surgery. These complications can limit vision, require further surgery and delay recovery. The use of anti-vascular endothelial growth factor (anti-VEGF) agents injected into the eye before surgery has been proposed to reduce the occurrence of these complications. Anti-VEGF agents can reduce the amount and vascularity of abnormal new vessels associated with PDR, facilitating their dissection during surgery, reducing intra- and postoperative bleeding, and potentially improving outcomes. OBJECTIVES: To assess the effects of perioperative anti-VEGF use on the outcomes of vitrectomy for the treatment of complications for proliferative diabetic retinopathy (PDR). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 22 June 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that looked at the use of anti-VEGFs and the incidence of complications in people undergoing vitrectomy for PDR.   DATA COLLECTION AND ANALYSIS: Two review authors independently assessed and extracted the data. We used the standard methodological procedures expected by Cochrane. The critical outcomes of the review were the mean difference in best corrected visual acuity (BCVA) between study arms at six (± three) months after the primary vitrectomy, the incidence of early postoperative vitreous cavity haemorrhage (POVCH, within four weeks postoperatively), the incidence of late POVCH (occurring more than four weeks postoperatively), the incidence of revision surgery for POVCH within six months, the incidence of revision surgery for recurrent traction/macular pucker of any type and/or rhegmatogenous retinal detachment within six months and vision-related quality of life (VRQOL) measures. Important outcomes included the proportion of people with a visual acuity of counting fingers (1.8 logMAR or worse), the number of operative retinal breaks reported and the frequency of silicone oil tamponade required at time of surgery. MAIN RESULTS: The current review includes 28 RCTs that looked at the pre- or intraoperative use of intravitreal anti-VEGFs to improve the outcomes of pars plana vitrectomy for complications of PDR. The studies were conducted in a variety of countries (11 from China, three from Iran, two from Italy, two from Mexico and the remaining studies from South Korea, the UK, Egypt, Brazil, Japan, Canada, the USA, Indonesia and Pakistan). The inclusion criteria for entry into the studies were the well-recognised complications of proliferative retinopathy: non-clearing vitreous haemorrhage, tractional retinal detachment involving the macula or combined tractional rhegmatogenous detachment. The included studies randomised a total of 1914 eyes.  We identified methodological issues in all of the included studies. Risk of bias was highest for masking of participants and investigators, and a number of studies were unclear when describing randomisation methods and sequence allocation. Participants receiving intravitreal anti-VEGF in addition to pars plana vitrectomy achieved better BCVA at six months compared to people undergoing vitrectomy alone (mean difference (MD) -0.25 logMAR, 95% confidence interval (CI) -0.39 to -0.11; 13 studies, 699 eyes; low-certainty evidence). Pre- or intraoperative anti-VEGF reduced the incidence of early POVCH (12% versus 31%, risk ratio (RR) 0.44, 95% CI 0.34 to 0.58; 14 studies, 1038 eyes; moderate-certainty evidence). Perioperative anti-VEGF use was also associated with a reduction in the incidence of late POVCH (10% versus 23%, RR 0.47, 95% CI 0.30 to 0.74; 11 studies, 579 eyes; high-certainty evidence). The need for revision surgery for POVCH occurred less frequently in the anti-VEGF group compared with control, but the confidence intervals were wide and compatible with no effect (4% versus 13%, RR 0.44, 95% CI 0.15 to 1.28; 4 studies 207 eyes; moderate-certainty evidence). Similar imprecisely measured effects were seen for revision surgery for rhegmatogenous retinal detachment (5% versus 11%, RR 0.50, 95% CI 0.15 to 1.66; 4 studies, 145 eyes; low-certainty evidence).  Anti-VEGFs reduce the incidence of intraoperative retinal breaks (12% versus 31%, RR 0.37, 95% CI 0.24 to 0.59; 12 studies, 915 eyes; high-certainty evidence) and the need for silicone oil (19% versus 41%, RR 0.46, 95% CI 0.27 to 0.80; 10 studies, 591 eyes; very low-certainty evidence). No data were available on quality of life outcomes or the proportion of participants with visual acuity of counting fingers or worse. AUTHORS' CONCLUSIONS: The perioperative use of anti-VEGF reduces the risk of late POVCH, probably results in lower early POVCH risk and may improve visual outcomes. It also reduces the incidence of intraoperative retinal breaks. The evidence is very uncertain about its effect on the need for silicone oil tamponade. The reported complications from its use appear to be low. Agreement on variables included and outcome standardisation is required in trials studying vitrectomy for PDR.

The effect of ethnicity on anatomic success following macular hole surgery: a multicentre cohort study.

PURPOSE: The purpose is to assess the effect of ethnicity on surgical macular hole closure. METHODS: A retrospective cohort study was undertaken in five UK National Health Service Hospitals. We included all patients with known ethnicity undergoing vitrectomy, internal limiting membrane peel, and gas/oil tamponade for all stages of primary full-thickness macular hole (FTMH). The primary outcome was anatomic success, defined as FTMH closure with one operation. The secondary outcome was mean change in best-corrected visual acuity (BCVA) comparing baseline with final review. RESULTS: Of 334 operations, the ethnicity profile comprised 78.7% White patients, 11.7% Black patients, 8.1% Asian patients, and 1.5% in mixed/other ethnicities. Mean age was 69.7 years with 68.5% females. Overall, 280 (83.8%) had anatomic success. Anatomic failure occurred in 38.5% of Black patients versus 12.6% of White patients (relative risk: 1.788; 95% CI: 1.012 to 3.159; P = 0.045). Overall, baseline logarithm of the minimum angle of resolution BCVA improved by 0.34, from 0.95 (95% CI: 0.894 to 1.008) to 0.62 (95% CI: 0.556 to 0.676). Mean BCVA improved by 0.35 in White patients, 0.37 in Black patients, 0.23 in Asian patients, and 0.38 in mixed/other ethnicity (P = 0.689). Greater FTMH minimum linear diameter was associated with an increased risk of anatomic failure (relative risk: 1.004; 95% CI: 1.002 to 1.005; P < 0.0001), whereas better pre-operative BCVA (F [1,19] = 162.90; P < 0.0001) and anatomic success (F [1,19] = 97.69; P < 0.0001) were associated with greater BCVA improvement. Socio-economic status did not significantly influence anatomic success or BCVA change. CONCLUSIONS: Black ethnicity is associated with an approximately twofold greater risk of failed FTMH surgery. The reasons for this difference warrant further study.

FUNCTIONAL AND MORPHOLOGICAL OUTCOMES OF THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE IN SMALL-SIZED AND MEDIUM-SIZED MACULAR HOLES <400 µm.

PURPOSE: To assess the effect of an internal limiting membrane flap (IF) in macular hole surgery on the best-corrected visual acuity (BCVA) and integrity of the ellipsoid zone (EZ) and external limiting membrane. METHODS: Patients were included who had successful surgery for macular hole <400 µm with or without an IF. Main outcome measures were BCVA and restoration of the external limiting membrane and EZ at 12 months. RESULTS: Sixty patients were included, 36 with conventional peeling and 24 with an IF. The best-corrected visual acuity improved from 0.74 (±0.30) logarithm of the minimum angle of resolution (20/110 Snellen) to 0.26 (±0.20) (20/36 Snellen) in patients without and from 0.77 (±0.32) logarithm of the minimum angle of resolution (20/118 Snellen) to 0.18 (±0.12) (20/30 Snellen) in patients with an IF, respectively. There was no difference in the integrity of the EZ and external limiting membrane in patients with or without an IF at either 3 (P = 0.58, P = 0.20), 6 (P = 0.81, P = 0.10), or 12 months (P = 0.60, P = 0.20) or in the BCVA at 3 (P = 0.24), 6 (P = 0.18) and 12 months (P = 0.11). In the multivariable model, only preoperative BCVA (P < 0.01), EZ integrity (P = 0.001), and age (P < 0.01) were associated with the post-operative BCVA. CONCLUSION: In patients undergoing surgery for macular hole <400 µm, the use of an IF did not affect the BCVA or the integrity of the EZ and external limiting membrane.

Visual Acuity Outcomes after Phacoemulsification in Eyes with Good Visual Acuity before Cataract Surgery.

OBJECTIVE: to analyse cataract surgery outcomes and related factors in eyes presenting with good visual acuity. SUBJECT AND METHODS: A retrospective longitudinal study of patients undergoing phacoemulsification between 2014 and 2018 in Moorfields Eye Hospital was conducted. Pre- and post-operative visual acuities were analysed. Inclusion criteria were age ≥40 years and pinhole visual acuity ≥6/9 pre-operatively. Exclusion criteria were no post-operative visual acuity data. The visual acuity change variable was also defined according to post-operative visual acuity being above or below the Snellen 6/9 threshold. RESULTS: 2,720 eyes were included. The unaided logMAR visual acuity improved from 0.54 to 0.20 (p < 0.001), the logMAR visual acuity with glasses improved from 0.35 to 0.05 (p < 0.001), and the logMAR pinhole visual acuity improved from 0.17 to 0.13 (p < 0.001); 8.1% of patients had Snellen visual acuity <6/9 post-operatively. Mean follow-up period was 23.6 ± 9.9 days. In multivariate analysis, factors associated with visual acuity <6/9 post-operatively were age (OR = 0.96, 95% confidence interval [CI] [0.95, 0.98], p < 0.001), vitreous loss (OR = 0.21, 95% CI [0.08, 0.56], p = 0.002), and iris trauma (OR = 0.28, 95% CI [0.10, 0.82] p = 0.02). CONCLUSIONS: Visual acuity improved significantly, although at least 8.1% of them did not reach their pinhole preoperative visual acuity. Worse visual acuity outcomes were associated with increasing age, vitreous loss, and iris trauma. The 6/9 vision threshold may not be able to accurately differentiate those who may benefit from cataract surgery and those who may not.

Accelerated, Pulsed Collagen Cross-Linking versus the Dresden Protocol in Keratoconus: A Case Series.

PURPOSE: The aim of our study was to compare the depth of the demarcation line developing in the cornea after the standard Dresden protocol versus the accelerated, pulsed, epithelium-off corneal collagen cross-linking (CXL). METHODS: This was a nonrandomized, retrospective case series. Patients with progressive keratoconus were treated with either the standard Dresden protocol (Group 1) or accelerated, epithelium-off CXL using the Avedro (Waltham, MA, USA) device (Group 2). The accelerated CXL protocol involved 18 min of pulsed ultraviolet-A (20 mW/cm2, 7.2 J/cm2, pulsed pro-file: 1 s on, 2 s off). The depth of the demarcation line was measured about 3 months postoperatively. RESULTS: Fifty-nine eyes of 35 subjects were included in the analysis. Group 1 consisted of 19 eyes, and Group 2 of 40 eyes. The mean age of the participants was 22.21 years in Group 1 and 26.55 years in Group 2 (p = 0.184). The mean preoperative K value was 44.89 D in Group 1 and 45.20 D in Group 2 (p = 0.768). The depth of the demarcation line was 322.50 µm in Group 1 and 319.95 µm in Group 2 (p = 0.937). CONCLUSIONS: The demarcation line depth was not statistically significantly different between the two protocols. The significance of the demarcation line depth has not been fully clarified in the literature. Our results support the contention that these two techniques may have similar structural outcomes and ef-ficacies in the treatment of keratoconus.

Inter- and intraobserver repeatability and reproducibility of choroidal thickness measurements using two different methods.

PURPOSE: To measure the inter- and intraobserver repeatability and reproducibility of choroidal thickness measurements taken by the enhanced depth imaging of spectral-domain optical coherence tomography (EDI-OCT) in randomly selected subjects using two different protocols. METHODS: Twenty subjects of the Thessaloniki Eye Study database were randomly selected. The participants underwent EDI-OCT, and the choroidal thickness was measured on EDI images using two different protocols. All images were assessed by two examiners independently in two sessions in different days. RESULTS: The interobserver intraclass correlation coefficient (ICC) for average choroidal thickness was 0.944. The average ICC for central, Cmin, and Cmax choroidal thickness was 0.899, 0.863, and 0.955, respectively. The interobserver ICC for average choroidal volume was 0.932. Intraobserver repeatability ICC for grader 1 ranged between 0.925 and 0.9720 and for grader 2 between 0.913 and 0.994. CONCLUSION: Choroidal thickness measurements by EDI-OCT showed a high inter- and intraobserver reproducibility.

Dislocation of a previously successful XEN glaucoma implant into the anterior chamber: a case report.

BACKGROUND: XEN glaucoma implant (XEN gel stent, Aquesys, Inc) is a new minimally invasive device approved for the treatment of glaucoma. CASE PRESENTATION: A 45 year old female was being followed and treated for primary open angle glaucoma in our tertiary referral center. Due to failure of medical treatment in controlling the glaucoma, surgery was offered to the patient. The XEN 45 µ-fistula implant was successfully placed in both eyes and adequate intraocular pressure control was achieved for 4 months. The left eye pressure then increased and the XEN implant was found in the anterior chamber. Topical intraocular pressure lowering therapy had to be re-initiated to achieve adequate pressure control. CONCLUSION: We describe a new potential complication of the XEN glaucoma implant.

Neovascular age-related macular degeneration: disease pathogenesis and current state of molecular biomarkers predicting treatment response-a scoping review.

Age-related macular degeneration is a major cause of blindness, and the development of anti-vascular endothelial growth factor (VEGF) intravitreal treatments has revolutionised the management of the disease. At the same time, new challenges and unmet needs arose due to the limitations of the current therapeutic options. Neovascularisation development during the course of the disease has a complex pathogenetic mechanism, and several biomarkers and their association with treatment outcomes have been investigated. We reviewed the relevant literature about neovascularisation development and biomarkers related to response to treatment. Improving our knowledge on the field can improve patient outcomes and offer personalised care.

Intraocular Tamponade Choice with Vitrectomy and Internal Limiting Membrane Peeling for Idiopathic Macular Hole: A Systematic Review and Meta-analysis.

TOPIC: A variety of different tamponade agents are used with vitrectomy combined with internal limiting membrane (ILM) peeling for the treatment of idiopathic macular holes. These agents include air, gas (sulfur hexafluoride [SF6], hexafluoroethane [C2F6], and perfluoropropane [C3F8]), and silicone oil. The optimal tamponade agent is uncertain, and we aimed to review the effect of tamponade choice on hole closure and visual outcomes. CLINICAL RELEVANCE: Although most surgeons initially chose to use long-acting gas (C3F8), there has been a gradual change in practice to the increasing use of the medium- (C2F6) and short-acting gases (SF6) or even air. However, there is no consensus regarding their relative efficacies. METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective and retrospective comparative cohort studies comparing different tamponade agents in patients undergoing vitrectomy and ILM peeling for primary idiopathic macular holes. For RCTs, the risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs, whereas for nonrandomized studies, the Risk of Bias in Nonrandomized Studies of Interventions tool was used. RESULTS: Thirteen publications, including 2 RCTs, were identified. Overall, there was no significant difference in the anatomic closure rates between studies using SF6 compared with either C3F8 or C2F6 (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.51-1.08). A subgroup analysis showed a significantly higher closure rate using SF6 (OR = 0.49; 95% CI = 0.30-0.79) in patients without postoperative posturing but not in those who were advised to posture facedown. The visual outcomes and adverse events were not significantly different. The comparisons of anatomic closure rates of patients treated with gas tamponade vs. silicone oil and with air vs. SF6 showed no significant differences. The included studies had a number of methodological limitations and heterogeneities, making conclusions imprecise, with low or very low certainty by the Grades of Recommendation, Assessment, Development and Evaluation approach. CONCLUSION: The current evidence base for tamponade selection with vitrectomy and ILM peeling for full-thickness macular hole has several major limitations. Further appropriately designed studies are needed to guide tamponade selection.

Phacoemulsification outcomes and complications in vitrectomised versus non-vitrectomised eyes.

Clinical relevance: Pars plana vitrectomy techniques have evolved in the recent years and the number of patients undergoing phacoemulsification for post-vitrectomy cataract has increased. Eye-care practitioners need to be aware of intraoperative complications and post-operative outcomes in previously vitrectomised eyes.Background: The aim of the present study is to compare the outcomes and related complications of phacoemulsification in previously vitrectomised versus non-vitrectomised eyes.Methods: This is a retrospective case-control study. Visual acuity, refractive outcomes, intra- and post-operative complications were analysed in consecutive phacoemulsification patients between January 2015 and August 2017. Patients with no post-operative data were excluded.Results: One hundred and forty-nine previously vitrectomised eyes and 608 non-vitrectomised eyes were included in the analysis. Previous pars plana vitrectomy was associated with worse logMAR visual acuity pre-operatively (0.75 ± 0.54 vs. 0.40 ± 0.33, p < 0.0001) and post-operatively (0.15 ± 0.29 vs. 0.09 ± 0.22, p = 0.014). There were no statistically significant differences between the two groups regarding refractive outcomes (p = 0.393) or posterior capsule rupture rate (p = 0.223). Previous pars plana vitrectomy was associated with a higher risk of post-operative macular oedema (p = 0.046) and posterior capsule opacification (p < 0.0001).Conclusions: Previous pars plana vitrectomy was not associated with a higher risk of intraoperative complications. However, a higher incidence of cystoid macular oedema and posterior capsule opacification were identified in the present study. Further research can provide insight into the mechanisms involved and any appropriate prevention strategies for these conditions.

Acute corneal melting one week after an uncomplicated cataract surgery in a patient who previously underwent eyelid radiation and with undiagnosed rheumatoid arthritis: a case report.

This is a rare case report of acute, paracentral corneal melting and perforation occurring 1 week after an uneventful cataract surgery, with discussions on possible pathogenetic mechanisms. Relevant literature was also reviewed. Herein, a case of an 86-year-old woman with acute, paracentral, and sterile corneal melting and perforation in her left eye at 1 week after an uncomplicated cataract extraction is described. This occurs at the base of ocular surface disorders due to previous radiation of her lower eyelid and cheeks for the treatment of cancer and previously undiagnosed rheumatoid arthritis. She underwent surgical treatment using Gundersen's conjunctival flap for the existing perforation due to low visual expectancies and reluctance to undergo corneal keratoplasty due to the risk of corneal graft rejection. The risk of coming across an acute corneal melting after an uncomplicated cataract surgery in the eyes with ocular surface disorders should always be considered.

Intravitreal bevacizumab prior to vitrectomy for proliferative diabetic retinopathy: a systematic review.

BACKGROUND: Diabetic retinopathy is a leading cause of visual loss in the working population. Pars plana vitrectomy has become the mainstream treatment option for severe proliferative diabetic retinopathy (PDR) associated with significant vitreous haemorrhage and/or tractional retinal detachment. Despite the advances in surgical equipment, diabetic vitrectomy remains a challenging operation, requiring advanced microsurgical skills, especially in the presence of tractional retinal detachment. Preoperative intravitreal bevacizumab has been widely employed as an adjuvant to ease surgical difficulty and improve postoperative prognosis.Aims: This study aims to assess the effectiveness of preoperative intravitreal bevacizumab in reducing intraoperative complications and improving postoperative outcomes in patients undergoing vitrectomy for the complications of PDR. METHODS: A literature search was conducted using the PubMed, Cochrane, and ClinicalTrials.gov databases to identify all related studies published before 31/10/2020. Prespecified outcome measures were operation time, intraoperative iatrogenic retinal breaks, best-corrected visual acuity in the last follow-up visit, the presence of any postoperative vitreous haemorrhage and the need to re-operate. Evidence synthesis was performed using Fixed or Random Effects models, depending on the heterogeneity of the included studies. Heterogeneity was assessed using Q-statistic and I2. Additional meta-regression models, subgroup analyses and sensitivity analyses were performed as appropriate. RESULTS: Thirteen randomized control trials, with a total of 688 eyes were included in this review. Comparison of the intraoperative data showed that bevacizumab reduced operation time (p < 0.001), minimized iatrogenic retinal breaks (p < 0.001), provided better long-term visual acuity outcomes (p = 0.005), and prevented vitreous haemorrhage (p < 0.001) and the need for reoperation (p = 0.001 < 0.05). Findings were strongly corroborated by additional sensitivity and subgroup analyses. CONCLUSION: Preoperative administration of bevacizumab is effective in reducing intraoperative complications and improving the postoperative prognosis of diabetic vitrectomy.PROSPERO registration number: CRD42021219280.

Factors associated with non-active retinal capillary density as measured with Confocal Scanning Laser Doppler Flowmetry in an elderly population: the Thessaloniki Eye Study (TES).

PURPOSE: To identify factors associated with retinal capillary density as measured with Confocal Scanning Laser Doppler Flowmetry (Heidelberg retina flowmeter (HRF)) in the Thessaloniki Eye Study (TES). METHODS: Participants of the TES (age ≥60 years, cross-sectional population-based study) were assessed for active capillary density in the superior and inferior peripapillary retina using the HRF. Pixel-by-pixel analysis was performed to quantify the percentage of zero flow pixels (ZFPs; surrogate for % retinal area with non-active capillaries). Multivariable regression analyses were performed to assess the association of non-active vascular density with ophthalmic and systemic variables. Glaucoma, late age-related macular degeneration and diabetic retinopathy subjects were excluded. RESULTS: 1189 subjects were included in the analysis. Older age (per year) was associated with higher percentage of ZFP in both the superior (slope estimate (SE)=0.0020) and the inferior (SE=0.0019) peripapillary retina (p<0.0001). History of migraine was associated with lower percentage of ZFP (SE=-0.0166) compared with no history of migraine in the superior peripapillary retina only (p<0.05). Higher intraocular pressure ((IOP) per mm Hg) and height (per cm) were associated with higher percentage of ZFP in the inferior peripapillary retina only (SE=0.0012, p<0.05 and SE=0.0005, p<0.05, respectively). The group consuming vegetables one to three times per week compared with the group consuming vegetables at least once a day had higher percentage of ZFP only in the inferior peripapillary retina (SE=0.0080, p<0.05). CONCLUSION: At a population level, our study revealed associations of older age, higher IOP and taller height with lower active retinal capillary density and of migraine with higher capillary density. Looking further into these associations may provide insight into disease mechanisms.

In-the-bag toric intraocular lens implantation in the case of an anterior capsule tear: a case series.

PURPOSE: To analyze the outcomes of in-the--bag toric intraocular lens implantation for anterior capsular tears during phacoemulsification. METHODS: The cohort of this re-trospective, consecutive, interventional case series included eight patients. One patient was excluded as the tear was used to enlarge the rhexis. The mean preoperative astigmatism was -1.67D (± 0.98) and the mean preoperative unaided logMAR visual acuity was 0.62 (± 0.76). The mean angle between the anterior capsule tear and the closest intraocular lens haptic was 51.25° (range, 30°-90°). RESULTS: The final unaided logMAR visual acuity was 0.16 (± 0.21) and the final cylinder was -1.1 D (± 0.59). The mean follow-up duration was about 2 ± 1.2 months. In this case series, no lens had to be explanted or rotated postoperatively. Placement of a toric intraocular lens in the presence anterior capsule tear was safe in all patients. An angle of at least 30° remained between the tear and the intraocular lens haptic. CONCLUSION: Placement of toric intraocular lens in the presence of an anterior capsule tear may be safe, at least in cases with a 30° angle between the anterior capsule tear and the intraocular lens haptic.

Factors Associated With Retinal Vessel Diameters in an Elderly Population: the Thessaloniki Eye Study.

Purpose: To identify the factors associated with retinal vessel diameters in the population of the Thessaloniki Eye Study. Methods: Cross-sectional population-based study (age ≥ 60 years). Subjects with glaucoma, late age-related macular degeneration, and diabetic retinopathy were excluded from the analyses. Retinal vessel diameters were measured using the IVAN software, and measurements were summarized to central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole to venule ratio (AVR). Results: The analysis included 1614 subjects. The hypertensive group showed lower values of CRAE (P = 0.033) and AVR (P = 0.0351) compared to the normal blood pressure (BP) group. On the contrary, the group having normal BP under antihypertensive treatment did not have different values compared to the normal BP group. Diastolic BP (per mm Hg) was negatively associated with CRAE (P < 0.0001) and AVR (P < 0.0001), while systolic BP (per mm Hg) was positively associated with CRAE (P = 0.001) and AVR (P = 0.0096). Other factors significantly associated included age, sex, alcohol, smoking, cardiovascular disease history, ophthalmic medication, weight, and IOP; differences were observed in a stratified analysis based on BP medication use. Conclusions: Our study confirms previous reports about the association of age and BP with vessel diameters. The negative correlation between BP and CRAE seems to be guided by the effect of diastolic BP as higher systolic BP is independently associated with higher values of CRAE. The association of BP status with retinal vessel diameters is determined by diastolic BP status in our population. Multiple other factors are also independently associated with retinal vessel diameters.

Anterior segment approach for the surgical management of aqueous misdirection syndrome.

We describe the surgical management of the aqueous misdirection syndrome through clear corneal incisions. A 20-gauge microvitreoretinal blade is used to create 2 side-port incisions. The same blade is inserted through the cornea and the iris for the main incision; it is then directed toward the center of the eyeball, passing through the zonular fibers to the vitreous cavity behind the pupil. Irrigation is delivered to the anterior chamber, the vitrector is placed in the vitreous cavity, and vitrectomy is performed. With this technique, aqueous misdirection can be resolved and adequate IOP control achieved.

Ranibizumab in the Treatment of Diabetic Macular Edema: A Review of the Current Status, Unmet Needs, and Emerging Challenges.

Diabetic retinopathy (more specifically diabetic macular edema, DME) is the most common cause of loss of vision in the working population in developed countries. Anti-vascular endothelial growth factor (anti-VEGF) agents considerably changed the treatment algorithms and improved prognosis of center-involving DME. Ranibizumab was the first approved anti-VEGF agent that revolutionized DME treatment. The vast increase in the number of patients undergoing intravitreal treatment and the role of anti-VEGF pharmacotherapy as the mainstay of DME treatment have triggered several challenges. Among them, of considerable interest is the quest for an optimal dosing scheme and the search for combination therapies. Although a significant body of research is directed towards other molecules that could potentially be new therapeutic targets, VEGF inhibition is expected to play an important long-term role in the treatment of DME considering the pathogenesis of the disease. Finally, recent studies revealed that ranibizumab may constitute a significant treatment modality in the management of other diabetic vision-threatening complications including proliferative diabetic retinopathy.

Macular morphology and response to ranibizumab treatment in patients with wet age-related macular degeneration.

PURPOSE: The purpose of this study was to assess whether specific characteristics of spectral domain optical coherence tomography (SD-OCT) affect structural and functional outcomes and number of injections needed in ranibizumab (0.05 mL of 10 mg/mL Lucentis solution)-treated wet age-related macular degeneration (AMD) patients. PATIENTS AND METHODS: This retrospective case series included 62 newly diagnosed wet AMD patients treated with three monthly intravitreal ranibizumab injections followed by monthly follow-up and pro re nata retreatment. The presence of dome-shaped pigment epithelial detachment (PED), disruption of the retinal pigment epithelium (RPE), and subretinal and intraretinal fluid was associated with changes in Early Treatment of Diabetic Retinopathy Study visual acuity, central macular thickness (CMT), and number of injections needed during the 6-month follow-up. RESULTS: The presence of PED was associated with lower values of CMT at presentation (399 µm [±132 µm] vs 310 µm [±51 µm], P=0.005). The presence of RPE disruption was associated with worse visual acuity in month 6 (0.36 [±0.22] vs 0.61 [0.45], P=0.027) and fewer injections (4.23 [±0.92] vs 3.55 [±0.60], P=0.007). The presence of intraretinal fluid at presentation was associated with worse visual acuity outcomes in month 4 (P=0.045) but not in month 6. CONCLUSION: The dome-shaped PED was associated with lower CMT at presentation, but it did not affect response to treatment. RPE disruption was associated with worse functional outcomes with fewer injections. Intraretinal fluid at presentation may suggest delayed response to treatment. Individualized SD-OCT analysis could lead to individualized approach to wet AMD patients. SD-OCT can offer imaging biomarkers to assess the prognosis of anti-VEGF treatment in AMD patients.